Focused Issue of This Month Drug Therapy and Catheter Ablation for Atrial Fibrillation Young Hoon Kim, MD. Division of Cardiology, Korea University College of Medicine Email : yhkmd@korea.ac.kr J Korean Med Assoc 2008; 51(4): 317-326 Abstract In all clinical trials comparing rate versus rhythm control of atrial fibrillation (AF) by drugs, there was no survival benefit associated with a rhythm control strategy. Currently used antiarrhythmic drugs are not only frequently ineffective at eliminating AF, but may be life threatening in some patients. Catheter ablation (CA) of AF has evolved rapidly and has become accepted as one of the therapeutic modalities for controlling AF. The effective strategies for CA of AF consist of pulmonary vein isolation (PVI) and/or complete encirclement around PVs with or without additional ablation lines. Selection of patients, who may be benefited by CA or not, is an important issue. Precise electroanatomic mapping for the triggers and the substrate of the atria is central for customizing ablation target and for enhancing efficacy of CA for AF. With further development of new energy sources of ablation, cardiac imaging, navigation, and mapping systems, the CA can be simplified and standardized, which may enable the CA to become more effective, safer, and more applicable to many different subsets of AF. Keywords : Atrial fibrillation; Catheter ablation; Antiarrhythmic drugs; Mapping 317
Kim YH Amio=amiodarone, Cath=catheter, Dofet=dofetilide, LVH=left ventricular hypertrophy Figure 1. Selection of antiarrhythmic drugs for the maintenance of sinus rhythm. ACC/AHA/ESC Practice Guidelines 2006. 318
Drug Therapy and Catheter Ablation for Atrial Fibrillation I avf V1 L1,2 L2,3 L3,4 L4,5 L5,6 L6,7 L7,8 L8,9 L9,10 ABL d ABL p PVP (*) elimination and dissociated during RF application RF=radiofrequency Figure 2. Dissociated pulmonary vein potential (PVP, *) from the let atrium after ablation. 319
Kim YH 250 200 150 100 50 PeAF PAF Freedom form AF recurrence (%) 100 75 50 25 P=0.061 Paroxysmal AF Persistent AF 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 0 10 20 30 PAF=paroxysmal AF, PeAF=persistent AF Figure 3. Number of catheter ablation of atrial fibrillation at Korea University Medical Center (KUMC, 1998~2007, n=680). 0 Figure 4. Longterm freedom from AF recurrence in patients with paroxysmal AF and persistent AF at KUMC (n=533). 320
Drug Therapy and Catheter Ablation for Atrial Fibrillation Selective PV lsolation vs. Empirical Fcur PVs lsolation SePVI EmPVI A B Figure 5. Selective arrhythmogenic pulmonary vein isolation (A) and empirical 4 pulmonary veins isolation (B). Pak HN, et al. J Cardiovasc Electrophysiol 2008 (In press). Cumulative AF Recurrence Rate AF Free Rate 1.0 % 30 0.8 25 0.6 15 0.4 10 0.2 5 0.0 0 0 10 20 30 40 50 29.723.1 months of Follow Up Time (months) 60 70 Figure 6. Atrial fibrillation recurrence rate after selective arrhythmogenic pulmonary vein isolation (SePVI) and empirical 4 pulmonary veins isolation (EmPVI). Pak HN, et al. J Cardiovasc Electrophysiol 2008 (In press). AF Free Rate (%) 321
Kim YH Figure 7. Automated map of complex fractionated atrial electrograms (CFAEs) during atrial fibrillation (6 seconds segment). The areas of white and red color illustrate CFAE with cycle length <80ms and <120ms, respectively. 322
Drug Therapy and Catheter Ablation for Atrial Fibrillation Before ablation After ablation Figure 8. Linear ablation along the complex fractionated atrial electrograms (CFAEs, white color denotes cycle length <120ms) during atrial fibrillation. Panel A shows automated CFAE map at baseline and panel B shows the summary of ablation of the antra of 4 pulmonary veins and linear extension to the areas showing CFAE. A B 323
Kim YH 10mV 5mV 0mV RSPV RIPV Anterior view LSPV POST VMPP Voltage Map Figure 9. Voltage map after isolation of 4 pulmonary veins and linear ablation at the roof and perimitral isthmus in patients with chronic, persistent atrial fibrillation. The voltage of the areas within the ablation lines convert to less than 0.2mV defining as gray color. LAA Line at the perimitral isthmus LSPV Posterior view roof line LIPV RSPV RIPV 324
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